Please complete this form for each child participating in VBS. Be assured that all personal and medical information will be held strictly confidential and only shared with VBS staff as necessary.
Child's Full Name*
Home address (Street & Town)*
Grade entering in Sept.
Are you or anyone in your family*
A member of the First Reformed Church of Lincoln Park
Interested in information about the Church or Sunday School
Custodial Parent(s)/Guardian Name*
List any court-appointed restrictions and/or custodial arrangements we would need to be aware of
Parent address (if different from above)
Emergency Contact - we will attempt to reach parents first.Name and Relationship*
Does your child have allergies or any conditions that would prevent him/her from participating in any of the activities of this program? *
If you answered yes to the above question, please explain - PLEASE LIST ALL ALLERGIES.
I understand that in the event medical intervention is needed, every attempt will be made to contact the persons listed on this form. In the event I cannot be reached in an emergency, I hereby give permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment and/or to order an injection, anesthesia, or surgery for my child as deemed necessary. I understand my insurance coverage for my child will be used as primary coverage in the event medical intervention is needed.I understand all reasonable safety precautions will be taken at all times by the First Reformed Church of Lincoln Park and its agents. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold The First Reformed Church of Lincoln Park, its leaders, employees and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form.
Photo/Video release: I hereby give permission for images of my child, captured during the activities sponsored by the First Reformed Church of Lincoln Park, through video and/or photograph, to be used solely for the purposes of The First Reformed Church of Lincoln Park publications, materials and/or website, and wave any rights of compensation of ownership thereto.*
Do not agree
I certify I am the legal guardian/parent for the above named child.
(Please indicate parent/guardian's name)*